Direct Deposit Authorization Form
Check One:
Full-time
Part-time
Student Worker
Name
Blinn ID Number
(Please Print)
Division
Contact Telephone Number
*
*(Failure to provide may delay timely salary payment.)
NAME OF BANK
CITY
STATE
TRANSIT/ROUTING NO.
ACCOUNT TYPE
ACCOUNT NUMBER
Checking
New Agreement
Savings (check only one)
Account Change
I hereby authorize Blinn College to initiate credit entries and to initiate, if necessary, debit
entries and adjustments for any credit entries in error to my account listed below.
This authority is to remain in effect until Blinn College has received written notification from me
of its termination in a timely and in a manner that affords Blinn College and Depository a
reasonable opportunity to act on it.
Will these payments be forwarded to a financial institution outside the United States?
Yes
No
SIGNED __________________________________ DATE __________________
Please attach a voided check
Jane A. Doe
3680
1000 Main Street
Anywhere, USA 10001
PAY TO THE ORDER OF:
EXAMPLE
_________________________________________
________________________________________________________
MEMO: __________________________________________
|: 123456789 |:
| Transit/ABA Number |
(First 9 numbers)
Revised 12/2013
DOLLARS
SIGNATURE: ______________________________________
11484620040 || 3680
| Account Number |
Check Number
(Do not include this number)